Fitzgerald, Daniel NEW YORK STATE DEPARTMENT OF HER�TH , t J Z Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel Joseph Fitzgerald Male
Date of Death Age If Veteran of U.S. Armed Forces,
6/20/2012 65 yrs. War or Dates 1 967-1 972
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
0 Manner of Death 0 Natural Cause D Accident D Homicide ElSuicide D Undetermined ri Pending
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Circumstances Investigation
ikt Medical Certifier Name Title
G C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 37
['Burial Date Cemetery or Crematory
;-::;;['Entombment 6/21 /201 2 Pine View Crematory
Address
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;;;Cremation Queensbury, New York
Date Place Removed
3❑Removal and/or Held
V. and/or Address
E,= Hold
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0 Date Point of
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f Transportation Shipment
0 by Common Destination
gl Carrier
El Disinterment Date Cemetery Address
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D Reinterment Date Cemetery Address
Ei Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
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F` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/21 /2 01 2 Registrar of Vital Statistics C 'C%L1 _4...
(signature)
': District Number 1 564 Place Town of Ticonderoga
1` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iti Date of Disposition '(Zsltt Place of Disposition F40qt+1 Cr rIW...
2 (address)
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CC (section) (lot number)i- (grave number)
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ci Name of Sexton or P rson in Char of Premises 44114,- JINN('
Z (please print)
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Signature Title hCotlic O
9 fl.
(over)
DOH-1555 (02/2004) •